How to increase uptake in oncologic screening: a systematic review of studies comparing population-based screening programs and spontaneous access

BACKGROUND

Cervical, breast and colorectal cancer (CRC) screenings are universally recommended interventions. High coverage of the target population represents the most important factor in determining their success. This systematic review aimed at assessing the effectiveness of population-based screening programs in increasing coverage compared to spontaneous access.

METHODS

Electronic databases and national and regional websites were searched. We included all studies on interventions aimed at increasing screening participation published between 1999 and 2009; for those published before, we consulted the Jepson et al. review (2000). We compared spontaneous access (including no intervention) vs population-based screening programs actively inviting the target population. Among the latter, we compared GP-based vs invitation letter-based interventions.

RESULTS

The invitation letter vs no intervention showed significantly more participation (RR=1.60 95%CI 1.33-1.92; RR=1.52 95%CI 1.28-1.82; RR=1.15 95%CI 1.12-1.19, for breast, cervical and CRC screenings, respectively). GP-based interventions, although more heterogeneous, showed a significant effect when compared with no intervention for breast (RR=1.74 95%CI 1.25-2.43), but not for cervical and CRC. No significant differences were found between invitation letter-based and GP-based organization (RR=0.99 95%CI 0.94-1.05; RR=1.08 95%CI 0.99-1.17, for breast and cervical cancer, respectively).

CONCLUSION

Population-based programs are more effective than spontaneous screening in obtaining higher testing uptake. Both invitation letter-based and GP-based programs are effective.

Meta-analysis: adherence to colorectal cancer screening and the detection rate for advanced neoplasia, according to the type of screening test

BACKGROUND

A variety of tests have been proposed for colorectal cancer (CRC), giving rise to uncertainty regarding the optimal approach. The efficacy and effectiveness of different tests are related to both screened participation and the detection rate.

AIM

To perform a meta-analysis on adherence and detection rates of CRC screening tests.

METHODS

Relevant publications were identified by MEDLINE/EMBASE and other databases for the period 1999-2012. A previous systematic review was used for the period before 1966-1999. RCTs and controlled studies including a direct comparison of the uptake rates among different options for CRC screening were included. Adherence and detection rates for advanced neoplasia and cancer were extracted. Risk for bias was ascertained according to CONSORT guidelines. Forrest plots were produced based on random-effect models.

RESULTS

Fourteen studies provided data on 197 910 subjects. Endoscopic strategies were associated with a lower participation (RR: 0.67, 95% CI: 0.56, 0.80) rate, but a higher detection rate of advanced neoplasia (RR: 3.21, 95% CI: 2.38, 4.32) compared with faecal tests. FIT was superior to g-FOBT with regard to both adherence (RR: 1.16, 95% CI 1.03, 1.30) and detection of advanced neoplasia (RR: 2.28, 95% CI 1.68, 3.10) and cancer (RR: 1.96, 95% CI: 1.2, 3.2).

CONCLUSION

The superior accuracy of endoscopy compared with faecal tests minimised any impact of the participation rate in determining the detection rate of advanced neoplasia in a screening setting.

[Atrial fibrillation: use of healthcare resources and expenditures in the Lazio region (Italy)]

Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia and is an important risk factor for mortality and morbidity related mainly to an increased risk of cerebrovascular events and heart failure.An observational cross-sectional study was performed to evaluate the use of healthcare resources (including hospital and outpatient care) by patients with AF in the Lazio region (central Italy), from 1 January 2006 to 31 December 2008.Atrial fibrillation is an important source of healthcare resource utilization because of repeated emergency room visits, hospital admissions, outpatient consultations and procedures and extensive use of laboratory tests and pharmacological treatments.Results show that 55% of costs are attributable to hospital admissions and Emergency Room visits, 37% to pharmacological treatment and the remaining 8% to outpatient care. These results are consistent with the international literature.The impact of AF in terms of cost is not negligible and it is therefore desirable to implement an organizational scheme that safeguards the appropriateness of care, taking charge of the patient as early as possible. The aims of early diagnosis of AF are to improve the appropriateness of care and optimize the use of specialized tests, thereby reducing hospital admissions for complications or recurrences of AF.

[Prioritizing prescriptions in a ambulatory care setting: a tool to achieve appropriateness of care in public health management]

Waiting lists are one of the main Public Health issues within developed countries. To promote appropriateness about General Practitioners' (GPs) prescriptions, during 2009 the project "Priority setting in outpatient prescriptions" in Latium Region has been approved. Regional referees, Latium Public Health Agency managers and advisors, managers and advisors of three Local Public Health Units (LPHUs) within the Latium region and some voluntarily recruited General Practitioners (each one with more than 800 patients enrolled) were included in a team work with the duty to develop the project. During two selected months of 2010, 46 GPs have forwarded overall 2.229 medical prescriptions. The six most numerous prescriptions were picked out and analyzed by the team work. 42% of these prescriptions were identified as belonging to category D of the priority level--"standard", while 42% and 41% of prescriptions bore the expressions of "control" and "diagnostic purpose" respectively. Among these ones, 75% were represented by bilateral mammography, prescribed to women aged between 50 and 69 years: but for those people bilateral mammography is already provided free of charge within the regional program of breast cancer screening, making the routine prescription by their physician a useless duplication, unacceptable in a healthcare system of good quality. Therefore at the conclusion of the project, the team work suggests proper standards be applied by healthcare professionals and GPs to achieve a significant objective: mammography appropriateness prescriptions.

Suspected transmission of tuberculosis in a maternity ward from a smear-positive nurse: preliminary results of clinical evaluations and testing of neonates potentially exposed, Rome, Italy, 1 January to 28 July 2011

We report preventive measures adopted after tuberculosis(TB) transmission from a nurse to a newborn assessed in late July 2011. All exposed neonates born between January and July 2011 were clinically evaluated and tested by QuantiFERON TB gold in-tube; newborns testing positive were referred for prophylaxis.Of 1,340 newborns, 118 (9%) tested positive and no other active cases of TB were found. Active surveillance for TB will be continued over the next three years for all those exposed.

[In the heart of the district. 50 interviews with the health professionals of the Lazio Region districts, Italy]

This article aims to explore some key issues relating to the health districts of the Lazio Region, in particular the major critical aspects as well as some strengths highlighted by the operators. In the Lazio Region there are 12 Local Health Units, divided into 55 health districts. In recent years, the majority of the authors analized theoretical models proposed by regional standards, while the strengths and weaknesses of the district, as well as the organizational difficulties and problems experienced daily by the operators have not been investigated. It was decided to use qualitative methods of research, through open interviews with 50 operators in 15 health districts of the Region. Interviews were analysed utilizing software Nvivo. Some codes were identified to guide interviews. We can summarize the emergency issues at least in three major areas: 1) the organization of the district, 2) the management of personnel and resources, 3) the care pathways. It is hoped that, during next years, the research directed at health district analysis will grow, with particular reference to quantitative and qualitative investigations, in order to build a body of knowledge from practical experience of health professionals.

[How to implement a unique triage system in the emergency departments of Latium, Italy]

Triage is an efficient system that emergency departments (EDs) use to sort out presenting patients on the basis of the speed with which they need treatment. Because triage is not used consistently in the EDs of Latium, a region in central Italy, the regional Public Health Agency (PHA) planned and implemented a regional model of triage in all EDs. This manuscript describe the regional implementation strategy. The PHA activated the "Regional Triage Program--RTP" including: development and testing of a "triage section" in the computerized EDs clinical chart; production of an operational handbook for the RTP for triage health professionals (HPs); implementation of an continuum educational program on the "RTP" in all EDs of Latium. The computerized triage section was tested and implemented in all EDs in the region. The handbook for triage HPs was produced. The educational program, has been ongoing since 2008 in all regional EDs. Selected HPs, identified as "facilitators", were trained on how to implement the RTP. They will organize, in their own EDs, small groups of nurses to conduct on-site training of the RTP. The RTP was received with enthusiasm by most HPs, however its introduction into current practice could be hampered by organizational/structural problems and conflicts between nurses and doctors. Next actions of the regional program will be to overcome the possible above mentioned troubles.

[Outcomes of hip replacement: a hospital-based longitudinal study in Lazio region (Italy)]

Hip replacement (HR) is a very effective procedure for chronic hip diseases especially in elderly. The aims of this study were: 1) to describe the typology of HRs; 2) to assess short and long term outcomes; 3) to evaluate the relationship between both individual and hospital characteristics with the outcomes. Regional hospital discharge data and mortality register were used. The study population included residents of the Lazio region, over 17 years of age, who underwent HR in any private or public hospital in Italy. We used logistic regression analysis to examine in-hospital mortality, 30-day mortality, 90-day mortality. Cox regression analysis was run to investigate revision and 3-5 year mortality. Out of 8159 HRs, 69.5% were total hip replacements (THR) conducted predominantly on females over 70 years of age. We observed 262 in-hospital deaths (7.4% endoprothesis, 1.4% THR). Thirty and 90-day mortality also showed a different pattern among the two procedures (endoprothesis 8.0% and 15.8%, THR 1.3% and 2.2%). At the end of the follow-up, 21% of patients had died and 204 revisions had been carried out (1.4% endoprothesis, 3.0% THR). Overall, 1898 patients (23.3%) had a revision or died. The main short and long term mortality risk factors were: age, male gender and comorbidities. Hospital volume was not associated with a significant mortality risk. For endoprothesis, waiting time before surgery longer than 7 days was associated with a 30-day mortality risk of 2.83. The present study prompted us to test methodologies to evaluate quality levels in orthopaedic surgery units throughout the region using information systems. Further studies are needed to better understand the variability in the characteristics of care that emerged in Lazio hospitals.

[Organizational appropriateness evaluation of hospital discharges related to DRGs at high risk of inappropriateness in a pediatric observation ward from 2000 to 2004]

The aim of the study is to measure and to describe organizational appropriateness of a Paediatric Temporary Observation Ward in the Emergency Department. We selected hospital discharges related to 43 DRGs at high risk of inappropriateness (DPCM 29/11/2001); we studied the relationship between appropriateness and patient's or discharge characteristics. We also investigated the inappropriateness to find tools for improving ward's efficiency. Assessment of selected paediatric clinical records was performed using PRUO protocol and showed that 41.5% of hospital discharges are completely appropriated and only 13.8% are completely not appropriated and, consequently, could be provided in a different organizational setting. Inappropriateness in our study is lower than the expected one; this finding shows that the ward under investigation is able to provide health assistance with good level of appropriateness. The used tool to evaluate appropriateness is a modified PRUO version, specific for pediatric hospital stays. Pediatric PRUO protocol is easy to be applied even if reasonable and shared evaluation criteria do not seem able to recognise some peculiar characteristics of Pediatric Temporary Observation Ward in the Emergency Department.

[Customer satisfaction in home care: methodological issues based on a survey carried out in Lazio]

Home care customer satisfaction has been, until now, rarely evaluated. After illustrating the main italian regional surveys on this issue, the article presents a customer satisfaction survey carried out in the district of Civitavecchia (Local Health Unit 'Rome F'), Lazio, regarding 30 home care beneficiaries. Methodological aspects emerging from the survey are basically focused on: advantages and disadvantages of quantitative and qualitative approaches (possibly associated each other); main criteria of eligibility of people selected for interviewing, both patients or caregivers; conditions that maximize answers reliability, including training on interviewers. Authors highlight opportunity of using such kind of survey, integrated with other different tools, into a systemic vision, for promoting management changes coming from suggested problems, aimed at total quality management.

[Epidemiology of femur fracture and characteristics of hospital care in Lazio]

We aimed at describing the epidemiology of femur fracture in elderly hospitalized for femur fracture in Lazio (Italy), and evaluating the association between patient's and hospital characteristics on in-hospital mortality. We conducted a population- and hospital-based study (Lazio region: 5.233.233 inhabitants) among people 65+ years aged.

SOURCE OF DATA

regional hospital register 2002-2003; ICD-9-CM codes for patients' selection 820 e 821. Direct standardization (rate x 1000) and logistic regression analysis (OR, 95% CI) were performed. Overall hospitalization rate in elderly was 7.5%o (10.l%o females vs. 3.9%0 males). 12.033 patients with femur fractures were enrolled in the study period; 21,6% were not treated surgically: in comparison with those who underwent surgery, they were males, residents out of Rome, older and with worst health status. In-hospital mortality rate was 7,97%. In-hospital mortality determinants were: male gender (OR=0.56), older age (85+, OR=3.30), living out of Rome (OR=0.50), comorbidities (Charlson 'index 3: OR=4.44), "others and unspecified parts of femur" as site of fracture (OR=1.84), admission to a private hospital (OR=O. 79) and a surgical treatment (OR=0.20). In conclusion, this study showed the effect of selected individual characteristics on in hospital mortality and suggested a role of early surgical treatment and access to private sector. Regional hospital information systems represent useful tools to address epidemiological impact of hip fracture and its health care resources utilization.

Influenza like Illness (ILI): prescribing behaviour of 83 sentry doctors in Lazio region in the period 2001-2002. Is it adherent to Italian ILI guidelines?

To describe different doctors' attitudes in drug prescribing in case of influenza-Like-Illness during 2001-2002 influenza season in Lazio region, with regard to consumption and expenditure and its adherence to Italian Guidelines on ILI Management. Prospective study aimed to assess doctors' behaviour in prescribing in respect with the following events: (a) ILI and subsequent controls after diagnosis, (b) complications, (c) adverse events to influenza vaccine. 7,629 subjects, have been identified and only 17% presents one or more comorbidities. There are totally 7,766 cases of ILI: 23% are complicated and out of the remaining 77%, only 14% presents comorbidities. Almost all elderly people have been vaccinated. Antibiotics were prescribed to complicated cases (82%) with comorbidities (55%); 1,075 patients (12%) had second or third contact with doctors in a period longer than 7 days and about 65% of them received antibiotics in case of acute bronchitis; children received mainly ibuprofen and paracetamol for fever control; acetylsalicylic acid in children group has been delivered only in 1% of cases. Overall, doctors' attitude in prescribing is generally coherent with Italian Guidelines on ILI even though a high variability still persists.

[Risk management in a regional screening program for breast cancer in the region of Lazio, Italy]

In the Lazio Region, it has been put into effect a plan of clinical Risk Management for the Breast Cancer Screening Regional Program (BCSP), involving all of the 12 Local Health Units and the Public Health Agency of Lazio (ASP). Being the BCSP a health care service, it consists of a perfect integration of health care structures, professionals and skills working for the citizens. This program originates from an unexpressed health need and leads to a evidence-based health benefit. The BCSP provides free breast screening for 700,000 women aged between 50 and 69 in the Lazio region; the Public Health Agency carries out the clinical governance of the BCSP The prevention of errors and incidents represents a fundamental basis of governance: it is a contribution to the achievement of efficacy in breast cancer screening. The BCSP deals with screening incidents from a systemic point of view and actively involves several Local Health Units staff going through each step of the whole patient's clinical path, from the identification of the target population, to the oncological treatment of positive cases. The programme is an integration of different tools: literature research, process analysis using the HFMEA methodology and reporting system. The results reached so far are the following: the regional severity rating scale, the regional Master-List of possible adverse events, occurrence and detection rating scale.

[Colorectal cancer screening: survey of endoscopy center's physicians in Lazio region]

The aim of the present work is to describe the characteristics of digestive endoscopy centers and the physicians that work there, with particular attention to their attitudes and practices in colorectal cancer screening. A questionnaire was sent to all 80 digestive endoscopy centers in the Lazio region, identified by the annual census of Italian Society of Digestive Endoscopy (Società Italiana di Endoscopia Digestiva, SIED). Seventy-one centers (89%), returned the questionnaire. Screening activity on average represents 14% of the centers' colonoscopy workload. Colonoscopy was considered to be a "very effective" screening test by 96% of physicians, the faecal occult blood test "very effective" by 20%, and flexosigmoidoscopy "very effective" by 11%. Ninety-seven percent (97%) of physicians reported recommending any test for screening: 80% colonoscopy, 61% faecal occult blood test, 14% double contrast barium enema and 11% flexosigmoidoscopy. Despite the fact that almost all physicians reported recommending screening, the centres are only marginally involved in screening practice. Endoscopy centers' physicians tend to have an aggressive strategy for colorectal cancer prevention and exclusive trust in colonoscopy; an attitude more consistent with a clinical-diagnostic approach than with real mass screening of a healthy population.

[Evaluation of the appropriateness of hospital admissions with the Italian version of the AEP in a university hospital]

It has been carried out a survey to evaluate the appropriateness of hospital stay in a university hospital. The aims of the study were: to determine the amount of inappropriate hospital admissions and inappropriate days of stay in relation to either wards and characteristics of admission; to analyse the reasons for inappropriate patient stay. A randomised sample stratified by ward of discharge of 224 medical records were analysed using the Italian version of the Appropriateness Evaluation Protocol. 37.9% of the hospital admissions and 18.9% of hospitalisation days were judged to be inappropriate. The main reasons for categorising an admission or a day of stay as inappropriate were a) delay in performing elective surgery procedures; b) that the patient's problem could be treated on an outpatient basis; c) delay in performing diagnostic examinations. The univariate statistical analysis showed an association between appropriateness of hospital stay and gender age, ward of discharge, length of hospital stay and DRG type (medical/surgical). The study highlights a lower level of inappropriateness compared to the results of other investigations. Hints were also identified for achieving an improved efficiency at hospital level.

[Evidence-based planning: the case of mass screening for colorectal cancer in the Lazio region of Italy]

Several population-based trials have shown the efficacy of colorectal cancer mass-screening based on guaiac faecal blood testing in a generic risk population. SCCR represents a very complex and resource-demanding public health intervention and, for this reason, its planning requires actual efficacy as a main goal. Since evidence of efficacy demonstrated by population-based trials may not actually generate effectiveness, the Regional Government of Latium Region decided to implement some experimental studies before introducing a screening programme, in order to define an evidence-based organisational model of SCCR and a feasibility evaluation of the real needs for screening. The aims of the pilot studies were to define an evidence-based organisational model, to evaluate the necessary resources and the actual quality standard of clinical examination, treatment and surgery. The aim of the feasibility study is to test the organisational model for SCCR for about 300,000 citizens residing in the Latium region. The present article illustrates the scheduling path set out, which is based on the involvement of experts, GP representatives and specialists from scientific societies and it is planned by the following actions: Definition of evidence-based recommendations; identification of further investigations; realization of experimental studies; definition of an evidence-based organisational model. The main research areas have been dealt with using randomised trials, in order to evaluate the efficacy of the involvement of GPs and the kind of test for RSOF Our work has produced evidences which were sometimes in contrast with information in the literature, demonstrating that guaiac RSOF testing is less reproducible and determines lower uptake than immunochemical testing. Our work also shows that the involvement of GPs should be based on their personal skills rather than on their role. Such evidences are fundamental to the definition of the organisational model and confirm the need of basing an evidence-based planning not only on evidences found in the literature. The necessity of this approach is strengthened by the level of organisational complexity and by the amount of resources needed to put a public health intervention into practice.

[Injuries in immigrants from non-industrialized countries: analysis of emergency admissions in Lazio, Italy, in the year 2000]

Aim of the study is to describe the characteristics of road, home and work-related traumas among adult immigrants born in non-industrialised Countries, and to compare the consequent probability of hospitalisation with Italian adults in Lazio Region, year 2000. Source of data is the Emergency-based Surveillance System, which collects all the emergency ward visits in Lazio region. Accident incidence has been estimated using alternatively the residence permits and the roman resident population born in non-industrialised Countries. The 7.7% of all the emergency visits of immigrants are trauma-related. Road traffic accident visits are more appropriate and urgent. Immigrants have a higher risk of hospitalisation both for road and home accidents compared to the Italians (OR = 1.59 and OR = 1.37 respectively). Immigrants use emergency wards for severe and urgent trauma-related accidents, they have higher probability of hospitalisation compared to the Italians. Our analysis highlights the necessity to improve tools to study immigrant health.

[A vaccination campaign for gypsy children in Rome]

Several studies conducted in Rome have shown low levels of vaccination coverage in gypsy communities. Thus a vaccination campaign targeting to 2400 gypsy children aged 0-13 years, present in 32 settlements in Rome, was conducted in 2002. The campaign was related to vaccinations required and recommended in Italy: diphtheria, tetanus, hepatitis B, pertussis (whooping cough), haemophilus influenzae and measles. In the majority of cases it was decided to carry out the vaccinations directly in the gypsy settlements, in accordance with the methods of pulse immunisation. In the case of small settlements a strategy for reorienting the population to vaccination centres was adopted. Around 2000 children were vaccinated, equivalent to 80% of the paediatric population present during the period. The number of children who have never been vaccinated has decreased from 40% prior to the campaign to 9% after the third week. Vaccination coverage in medium- and small-sized settlements (<200 inhabitants) after the campaign shows values of over 70%; in the large settlements, more modest increases have been recorded and coverage has rarely exceeded 50%. This experience has highlighted the importance of networking between public healthcare institutions and non-profit organisations. The mobilisation of a wide range of competences has thus enabled the attainment of a high level of effectiveness.

[Health conditions of immigrant women in Italy]

The number of immigrant women in Italy has increased from 260,000 in 1991 to at least 750,000 in 2003. This article describes the health situation of these women, in particular it deals with reproductive health. Immigrant women are generally young, in good health and they go to the health services mainly for pregnancy, delivery, spontaneous and induced abortion. Forty-eight per cent of acute hospital admissions and 56 per cent of day hospital admissions in 2002 were related to reproduction. Among foreign citizens, the induced abortion rate is three times higher than that reported among Italians, while the risk of spontaneous abortion is similar (97 per thousand and 101 per thousand, respectively). In general, the data show that immigrant women in Italy live in deprived social conditions, which can influence their reproductive choices and their access to health services. In order to take account of their particular needs, it is necessary to modify the health services and plan public health interventions especially for the prevention of induced abortion.

Home breastfeeding support by health professionals: findings of a randomized controlled trial in a population of Italian women

AIM

We conducted a randomized controlled trial to assess the effectiveness of a support intervention delivered by health professionals to increase the rate and duration of breastfeeding.

METHODS

A randomized controlled intervention study was conducted in the period 2000-2001 among 605 mothers who had given birth in a public maternity ward located in the city of Rome, Italy. The intervention consisted of a home visit by a midwife from the maternity ward of the hospital. The outcome of the study was the infant's feeding habits, assessed by a 24-h recall. The effect of the intervention on the duration of breastfeeding was estimated by the Kaplan-Meier method and by the Cox multivariate regression model.

RESULTS

According to intention-to-treat analysis, there was no significant difference between the intervention and the control group, after controlling for confounding factors (hazard ratio (HR) 1.04; 95% confidence interval (95% CI): 0.85-1.26). The duration of breastfeeding was shorter (HR 1.61; 95% CI: 1.13-2.31) for women in the intervention group who refused the obstetric visit.

CONCLUSION

Our study shows that an early home support programme delivered by health professionals was not effective in increasing breastfeeding initiation and duration.

[Epidemiology of tonsillectomy and/or adenoidectomy in Italy]

OBJECTIVES AND METHODS

Aim of the study was to describe frequency, causes, regional variations, setting and risk of mortality of tonsillectomy and adenoidectomy in Italy. The study is based on hospital discharge data for the years 1998-2000 provided by the Ministry of Health.

RESULTS

During the year 2000, 61.280 tonsillectomy with or without adenoidectomy and 32.655 adenoidectomy alone were performed in Italy. ICD-9-CM codes reported on discharge abstracts indicated that the most frequent causes of tonsillectomy were chronic tonsillitis (45%) and hypertrophy of tonsils and adenoids (43%). The total tonsillectomy rate was 10.6 x 10.000 (CI 10.5-10.7) in 2000, and it was stable throughout the study period. We observed a wide geographical variability of regional tonsillectomy rates, standardised by age and sex. They ranged from 3.5 x 10.000 (CI 3.1-4.0) in Basilicata to 19.0 (CI 18.6-19.5) in Piemonte. We found an inverse correlation (r = -0.50) between regional tonsillectomy rates for tonsillitis and minimum temperatures recorded in capitals of the regions. Most operations were performed in the acute setting with a hospital stay longer than one day. The mortality risk associated to surgery was estimated to be at least of one case over 95.000 operations.

CONCLUSIONS

The observed variability of regional tonsillectomy rates, only partly explained by weather differences, may be ascribed to disagreement among physicians. Inappropriate variations and setting were the two main reasons conducive to the development of the guidelines "Clinical and organisational appropriateness of tonsillectomy and/or adenoidectomy in Italy", in the frame of LINCO project and of the Italian National Program for Guidelines.

[Factors related to in-hospital mortality after stroke in Lazio region, Italy]

The use of hospital discharge abstracts in estimating the outcome of hospital care represents an ongoing interest in public health. However standardized methodologies are still not available. We carried out a retrospective study to estimate the association between demographic and clinical characteristics and in-hospital mortality after stroke by using administrative data from the Hospital Information System in Lazio Region. We also assessed the relationship between the presence of neurology services and the outcome. We found 12,781 incident episodes of stroke (main diagnosis ICD-9: 430-431-434-436) (49.3% male, mean age = 74 years) admitted in 126 hospitals in the Lazio region for the period 1999-2000. From the hospital discharge abstracts we collected patient demographic and clinical data. The hospitals were classified in centres with and without neurology services. Admissions to hospitals with neurology services were evaluated as predictors of in-hospital mortality after adjustment for gender, age, residence, education, source of admission, type of stroke, heart disease, kidney disease and history of atrial fibrillation. In-hospital mortality (within 30 day) was 25.1%. Female gender, advanced age, residence in Rome, urgent transport, kidney disease and history of atrial fibrillation were associated with an increased risk. Hemorrhagic stroke (ICD-9 = 430-431) had a worse outcome than ischemic stroke (ICD-9 = 434) and acute undefined cerebrovascular disease (ICD-9 = 436). Patients admitted to hospitals with neurology services showed a significantly decreased risk (OR = 0.88, IC95% = 0.79-0.98), particularly in occlusion of cerebral artery (ICD-9 = 434) and in undefined cerebrovascular disease (ICD-9 = 436). Demographic and clinical variables are associated with the outcome of hospitalised stroke patients. Admissions of acute stroke patients in specialized hospitals seem to play a role in reducing the risk of in-hospital mortality.

[The outpatient care in the Latium region (Italy) in 2001]

The Region of Latium has been operating an Outpatient Care Information System (SIAS) since 1997 to monitor the supply of outpatient care in a territory with a population of over five million. The present work has the aim of describing the outpatient care in the region, in terms of number of facilities involved by category (public and private, operating in the regional public health system) and volume of procedures rendered to residents in 2001. Of the 971 outpatient facilities operating in hospitals and elsewhere--37% state managed and 67% private--distributed in a non-uniform manner throughout the region, the majority is concentrated in the city of Rome, which by itself accounts for 49% of its total amount of facilities, and in a lesser measure in the other provincial capitals (Viterbo, Rieti, Frosinone, Latina). In 2001, 71 million procedures were performed, comprising 17 million prescriptions, for an economic value of over 400 million Euros. The three specialties of greatest use were Lab Analysis, Physical Therapy and Rehabilitation, and Radiology, making up 88% of the total outpatient procedures performed within the precinct of the regional health service, in respective measures of 57%, 27%, and 4%. It is noted that the public facilities are prevalently polyspecialistic while a great number of private facilities are monospecialistic and perform procedures almost exclusively (96%) in the three specialties of greatest use. The other specialties which receive notable use are Cardiology, Eye Care, Orthopedics and Neurology. In general, the greater the number of facilities there are in either the public or private sector, the greater the level of activity in terms of procedures performed, with the exception of the area of Physical Therapy and Rehabilitation where the correlation is inversely proportioned; in fact, for this specialty the public facilities, which are represented in a much greater number throughout the region, supply only 7% of the volume of activity.

[The emergency refund system in Lazio region: features and problems]

In Lazio region, in which Rome is located and 5,300,000 inhabitants live, an Information System has been started since 1999 to collect personal and clinical data of the admissions to Emergency Departments. The present work describes the fundamental aspects of the Region refund system for the emergency services made by the Emergency Departments. The article shows both the features of the information flow, on which the financial evaluation is based, and the fundamental steps of the regional deliberations for the years 2000 and 2001. We introduce the refund evaluations by 13 local health authorities (ASL) constituting the regional health service, for the years 2000-2001, and we point out the major problems related to calculation procedures. The total amount of emergency admissions in the region is 1,973,930 (year 2000) and 2,188,885 (year 2001). The evaluated charge for the region is 145,569,340 Euro (year 2000), and 170,004,718 Euro (year 2001).

[Evaluating hospital appropriateness with different tools: administrative data versus analytic review]

PRUO, a modified version of AEP, is a widely used clinical-based tool to evaluate hospital appropriateness in Italy. We developed the APPRO method for assessing organizational appropriateness using administrative data. APPRO estimates the amount of inappropriate hospitalisation, giving consideration to severity of illness through APR-DRG classification system. The aims of the study were to: measure the agreement between evaluators using PRUO; investigate the relation between APR-DRG severity subgroups and PRUO assessment; asses the validity of APPRO method comparing its performance to PRUO results. We selected 361 hospital episodes assigned to DRG 39 ("lens procedures with or without vitrectomy") and 242 hospital episodes assigned to DRG 183 ("miscellaneous of digestive disorders, age > 17") from three hospitals in 2000. Clinical records were independently evaluated by two pairs of physicians using PRUO. Proportions of inappropriate episodes by hospital and DRG were also estimated through APPRO using data from Lazio regional hospital information system. The agreement between the two pairs of evaluators was high (k=0.93; p<0.0001). We observed no statistically significant association between APR-DRG severity subgroups and inappropriate hospitalisation found by PRUO. APPRO underestimates rates of inappropriate hospitalisation compared to PRUO. It depends on the different characteristics of the tools and particularly on the caution of APPRO in performing the evaluation using routine data.

[Management of vaccination practices in adults: the influenza vaccination campaign in Lazio region, Italy]

This paper focuses on key issues of the organizational model of the influenza vaccination campaign in Lazio region, Italy, started during the 1999-2000 season. The following crucial features of the model are emphasized: a strong support given by Regional Health Agency; a high level of commitment of local health authorities; a considerable involvement of general practitioners; the appropriation of economical incentives related to different levels of coverage; an "ad hoc " information system. The model resulted in a remarkable increase of the number of vaccinations among elderly population (from about 420,000 in the 2000-2001 vaccination campaign to about 560,000 in the successive campaign) and of the correspondent levels of coverage (from 45.7% in the 2000-2001 vaccination campaign to 59.2% in the successive campaign). Nevertheless, further efforts should be provided to better identify population at risk, and to reach the most disadvantaged groups. Moreover, actions are to be performed to assess health and economic benefits of vaccination campaign, in order to improve the efficiency of health care planning programs.

[Comprehensive assessment in public health]

The Italian health system has been completely public for 25 years; it is now adopting a federal structure conferring to the single regions a leading role in public health management. Therefore clear evaluation methods and tools need to be adopted in order to guarantee equity-based decision making. Multidimensional evaluation, a method first developed in the geriatric setting, represents an extremely useful tool both to establish the best profile of assistance and to guide the management of different services. It is mainly used to evaluate health status and needs for assistance within non self-sufficient populations, largely composed of the elderly. Currently available assessment tools reveal different approaches, goals and level of accuracy. The authors have examined and compared 21 different multidimensional assessment tools adopted in Italy with a standardized method based on pre-established data collection and evaluation criteria. Both quantitative (number of items used for every single dimension or sub-dimension) and quali-quantitative aspects (level of detail for every single dimension or sub-dimension) are included in the analysis. Tools were also evaluated according to the degree of fulfilment of certain fixed requirements. In the authors' opinion, given a specific assistance setting and its users, once the goals and requirements of the evaluation instrument are clearly defined, adopting this methodology--defined as "Progressive exclusion method for easier visualization of criteria correspondence and quali-quantitative aspects", would help to identify the most suitable assessment tools to be used. The authors hope that, on a regional level, the public health system will make a greater use of homogeneous multidimensional comprehensive assessment tools in order to foster both a uniform approach towards the needs for assistance and transparent criteria of resources allocation in public health services.

[The quality of medical records: a retrospective study in Lazio Region, Italy]

INTRODUCTION

Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice.

PURPOSE

We performed a retrospective study in order to assess the quality of medical records in the Lazio region.

METHODS

From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires.

RESULTS

A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items: presence of anamnesis 98.1% (range: from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range: from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range: from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate.

CONCLUSIONS

Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.

Implementation of a surveillance system for stroke based on administrative and clinical data in the Lazio region (Italy): methodological aspects

Stroke is the third leading cause of death and the most important cause of long-term disability in Italy and other developed countries, heavily influencing quality of life and costs of health care. In spite of the widespread occurrence of the disease and its relevant impact in Italy, there is neither a national nor a regional surveillance system of cerebrovascular diseases. A regional surveillance system for stroke has two important aims: to help to interpret the geographical and temporal trends of the disease for health care planning and resource allocation and to allow close monitoring of the quality of stroke services. Age-standardized mortality rates for cerebrovascular diseases in the Lazio region (5,242,709 inhabitants) in the period 1998-99 were 69.4 for males and 59.4 for females per 100,000 inhabitants. In the year 2000, about 3% of all hospital discharges were for cerebrovascular diseases with a hospitalisation rate of 4.36 per 1000 inhabitants. The mean length of stay is 12 days (median of 9 days) and in-hospital death is 15.4%. The admission rate for cerebrovascular diseases to emergency departments is 3.40 per 1000 inhabitants. The goal of the Lazio Regional Health Authority is to implement a surveillance system for stroke based both on current data (mortality and discharge data) and on information collected in a registry for quality assessment of stroke care. The first step of the study is to develop a regional register of acute stroke using an 'ad hoc' data sheet integrated in the computer-based patient record system of clinical and administrative data (GIPSE) operating in all emergency departments in the region.

[Hormonal contraception in 46 public family clinics in Rome]

This study investigates the role of 46 public Consultori of Rome, as far as the hormonal contraception with "pill', the most common contraceptive method used by roman women, is concerned. With a series of phone calls, a hypothetic potential customer asked for an appointment directly with the gynaecologist for getting adviced to use "pill" for the first time. The results show that, although the wait for the first appointment directly the gynaecologist is not long (11,3 days as an average), it is very difficult to get it and this was possible only in 12 cases out of 46. We have noted that the first appointment for "pill" was offered with no-medical personnel, like social assistants, sanitary assistants or midwives, in most 16 of cases, and that in a significant number of Consultori was not possible to obtain an appointment whatever. In public Consultory of Rome we have found a different attitude in giving appointment to women for contraception with pill, even inside the same USL (Local Sanitary Unit, the basic structure of public health in Italy, in which Consultori have the role of prevention and promotion of maternity and tutelage of infancy). From this study the need emerges of uniformity in the attitude of Consultori staff in managing the customers, in order to avoid that women, finding so many difficulties, give up referring to these public structure for beginning contraception and choose private professionals or decide not to use the "pill".

[Verification of antibiotic treatment after animal bites among patients at the antirabies center in Rome]

The study aimed at searching whether antibiotic prophylaxis was practised after animal bites, and, in this case, what were the criteria adopted. It was performed by considering 162 outpatients requiring assistance after animal bites at the Antirabies Centre of Rome, Italy. In this circumstances, prevention of bacterial and viral infections is performed by wound detersion, by administering anti-tetanus and anti-rabid prophylaxis where required by italian policy, according to the patient's history. Infectious complications are described in literature as a common consequence of animal bites and include cellulitis, septic arthritis, osteomyelitis and even fatal sepsis. Microorganisms related to these infections are frequently typical of animal oral flora and include aerobic and anaerobic species, such as Pasteurella multocida, DF-2, and Leptospira. It was noted that 58 (35.8%) out of 162 were treated with antibiotic prophylaxis; the most common drug used was amoxicillin, given in 18 cases (31%). The overall results do not show any particular reason for practising or not this prophylaxis. The need of standardising the behaviour of Emergency Services, where a different and unjustified attitude to treat or not patients with antibiotic prophylaxis in order to prevent infectious complications following animal bites was observed, emerges from this study.

[Problems of laundry hygiene]

As the bacteria found more frequently in hospital infections are the same found in the linen, it is speculated that hospital linens can contribute to the spread of nosocomial patologies. Nevertheless this consideration does not prove that linen constitutes a significant source for transmission of hospital infections, although some studies have strengthened this possibility. The hygienic problems of hospital linens washing have a great importance and in this contest the possibility of contagion throught infected sheets or overalls constitutes only a part of the question. The problem of the spreading of nosocomial infections has to be divided into (1) collection and arlage of the linens; and (2) their disinfection and washing. Collection and carriage need precautions to prevent the hospital staff and the patients from the direct contagion, while during the washing the infected, or potentially infected, linen are to be regarded as a potential risk, which can be avoided through a disinfection before the standard washing cycle. During the washing the processes of cleansing, the dilution and the effect of temperature could be sufficient to obtain the final results. The last consideration is linked to gestational aspects, that's to say the consumptions, the costs, the traditional organizing procedures and the alternative ones, such as the possibility of substituting disposable material to linens or to refer to central laundries placed outside the hospital building and independently operated.